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The person who experienced the problem should normally complete this form. If you are completing this on behalf of someone else, please fill in Section B.

Please note that before taking forward the concern we will need to satisfy ourselves that you have the authority to act on behalf of the person concerned, this may involve us contacting that person to gain their consent.
SECTION C: Details about the concern

If you are raising this concern on behalf of someone else, what is your relationship to the patient?

In your opinion, what went wrong?

Describe how you or others have suffered or have been affected by this incident/event.

What do you think should be done to put things right?

Date event/incident occurred

Have you already put your concern to the frontline staff responsible for delivering the service? If so, please give brief details of how and when you did so.

SECTION D: Please choose how you would like us to contact you

PostEmailPhoneFace to facePlease identify any special requirements below so that we can discuss how we might help you:English is not my first languageI have a sensory impairmentI would like assistance with raising my concern